Nick's Blog

Quality of Care

Back in the 70's, competitive marching bands came into vogue in Western Pennsylvania. Let me explain the before and after of this phenomenon: Before there were competitions, bands were made up of  nearly 10 times more students than they typically have today. My bands ranged in size from 120 to 185 students. Once competition came into play, the borderline students were not able to survive.  Consequently, it is not unusual now to have 20 students or less in a band.

What's happening in medicine and in health care overall?  The Government is taking a three-pronged approach to improve quality in health care:

1.  They are pushing quality through public reporting.  (Check a website near you.)

2.  Enforcing quality through the False Claims Act.  (Check a prison near you.)

3.  Incentivizing quality through payment reform. (Check a checkbook near you.)

Senator Chuck Grassley is quoted as saying, "Today, Medicare rewards poor quality care.  That is just plain wrong, and we need to address this problem."

HMO's are currently embracing "pay for performance" plans for physicians and hospitals.  Medicare is introducing value-based purchase plans.  Medicare is proposing the linking of quality outcomes to physician payments.

As I have written before, hospitals will no longer be paid for hospital acquired conditions. That seems like a rather simple fix, but to appropriately determine if the condition was not acquired at the hospital, extensive testing must be added pre-admission at considerable costs to the hospitals. 

James G. Sheehan, Medicaid Inspector General of New York said, "We are reviewing assorted sources of quality information on your facility to see what it says and if it is consistent.  You should be doing the same."  

Except for the financial implications, not unlike my competitive band story, the goal was to work toward perfection. The public reporting of quality of care is intended to:

1.  Correct inappropriate behavior

2.  Identify overpayment's

3. Deny payments

The False Claims Act, on the other hand has different goals. When asked how he viewed the False Claims Act, Kirk Ogrosky, U.S. Deputy Chief for Health Care Fraud said, "You will see more and more physicians going to jail."   I guess the prisoners will be receiving better care.

Where's it all going?  Competitive band.  Will it improve health care delivery?  Probably, for the patients who can find the few docs and hospital that will be left?  I recently had a conversation with a young computer specialist who took care of physician practices.  He said, "Doctors and hospitals haven't figured it out yet, but they are simply becoming data entry centers for 'Big Brother' as the facts and figures are accumulated to be used against them any way the payers decide to move forward."

Looking back at the school year that included gym class twice a week for the entire year, rich courses in music and art, and remembering a time when priorities included those classes intended to make every student well rounded, we have to ask, "Is education today better?" 

Maybe this is all too complicated to get our arms around, but if there are 78 million Baby Boomers, and the Medicare Trust Fund is heading toward bankruptcy, then we probably will see every rule in the book being applied to keep from paying out money, because there is simply not enough money to go around. 

Will health care improve?  Once we understand that technology is not the end all and cure all that creates healing; once we endorse prevention, wellness, optimal healing environments, and systems approaches to health and wellness, health care will improve.  I'll bet you that it will have very little to do with the rules that are unfolding right now and much more to do with the creation and acceptance of a National Health Policy.   

Building a Building . . . Without Enough Cash!

We're between the devil and the deep blue sea . . . Here's the story: Four years ago, the idea to create a virtual showcase room as the crown jewel for the hospital was born.  Because of my education background, the missing link for me had always been our inability to meet at any given time with large numbers of employees, community members, patients, or supporters.  We could hold about 50 or so in our largest room, but had no place to have a larger meeting on campus.  

Because of that, we held our Showcase for Biotech in downtown Johnstown, and no one got to visit our research center as part of the program. We had ideas for a kids fitness center for diabetes control and obesity, a center for spiritual healing services, for meeting with half of our employees at any given time, for holding special classes and workshops, and for education.  There were also plans to use it for a meeting place for our physicians and for support groups. 

Unfortunately, or fortunately, depending on your point of view, the idea really got very little traction from donors or potential donors.  As the years wore on, it seemed more and more hopeless.  Then, we decided to turn it into a project that could be funded through grants, and we began turning over rocks in every area, and found grants of $240 K here and $100 K there, another $150 K from donations a commitment for $100 K more until we reached the last $100 K needed to kick off the project.  We had business plans to support the facility, drawings, and even held a ground breaking. 

Then the mortgage crisis hit, and bonding for contractors became a precious commodity.  The low bidder did not receive the total bond needed to ensure safety for the hospital's investment, and the project went on hold.  Because that bidder came in at about $700 K, and could not get his bond, we were forced to go to the next lowest bidder who was approximately $250 K higher than the original low bid.  Back to the drawing board.

We asked them to lower the project cost, and they couldn't. Consequently, we cut 1/3 of the project, the meditation room, the walkway, the dividing section, over 1/3 of the space and, guess what? Because materials have escalated so dramatically in the past six months, that contractor came back at almost exactly the same price. Not only was it the same price, because the material continue to go up so rapidly, they could only give us 7 days to hold the bid.

So, we went to another construction company. and they came in about $30K higher than the second bidder.

Once again, back to square one. I had a commitment from a donor for another $100 K but they had to back out because they weren't able to sell a commercial building that would have funded the donation. Then, we got an additional $100K, and the  promise of more from another government source.

So, the predicament we are in is that, if we don't do the project, we send all of the money back, including money we have already spent on architects. More importantly, there will be little to no hope for future funds from any of these sources. Consequently, I sit here frustrated once again, with soggy corn flakes,  wondering what the next steps will be.

So, there you have it. To jump or not to jump . . . based on faith, hope and charity?  That's the way it works in non profits. 

p.s.

Since posting this blog, one of our donors accelerated their donation and applied it to this project.  Work starts this week!!!

Hospital Bullies take a Toll on Patient Safety

That was the title of an article written by JoNel Aleccia for MSNBC.com.  When I thought about writing this blog, a cold chill went down my spine. The last time I attempted to address this issue, I was attacked, not here, but from other places. My family was hassled, there were letters written to the paper, to my board, to the Medical Society and demands for apologies all around. This article, however, took a much tougher stand than I did, and made its point much better than I did as well. 

JoNel started by writing, "They're the bullies of the operating room, the brow beaters of bedside manner; doctors, nurses and other clinicians who make a habit of behaving badly."  Before you start sending me your hate E-mails and trying to get me fired, censured, and publicly whipped again, let me begin by saying that there are only about 4 to 6% of workers and staff nationwide who typically fall into this category, and, in our case, I can honestly and proudly say that at Windber Medical Center there are less than 1%, but that's not the point.  The point is that this type of behavior is still tolerated ANYWHERE. 

Ms. Aleccia goes on to say, "They yell, they cuss, they throw things. Or they engage in more subversive behaviors; ignoring questions, acting impatient, insulting colleagues or speaking to them in condescending tones."  Any of us in this industry who have not observed this behavior should please stand and be recognized.  Interestingly, the Joint Commission has recently taken a stand against bullying behavior with a first-ever alert, and the reason for their alert is patient safety.

Dr. Mark Chassin, President of the Joint Commission, says, "It's a problem that goes underreported, threatens patient safety and has become so ingrained in healthcare that it's rarely talked about."  (So, send your evil E-mails to Mark, and let me alone.)

Dianne Felblinger, an associate professor of nursing at the University of Cincinnati who studies medical intimidation goes on to state that "About 70% of nurses studied believe there's a link between disruptive behavior and adverse outcomes, and nearly 25 percent said there was a direct tie between the bad acts and patient mortality."

The great news is that Windber Medical Center's Administration, Medical Executive and Credentials Committees and Human Resources Department deal with these behaviors immediately. They do not and will not tolerate bullying.  Oh, and before we end this blog post, remember, this behavior is NOT limited to care givers; clearly, administrators, department heads, and others can be just as guilty.   

The advice given in the article is the same advice that we adhere to here at WMC as well.  When someone is disruptive we should simply say, "You know what...? That doesn't work here...And we're going to have to do this together as a team because that's what it's all about."

Amen!

The Hospital of the FUTURE . . .

Healthleaders magazine had a cover story entitled "The Hospital of the Future" written by Molly Rowe.   The line below the title read: "Sure, your organization offers sophisticated, compassionate care.  But the patient of tomorrow will want much more than that.  Here's how some hospitals are creating facilities for a new vision of healthcare." 

Rather than re-write the entire story, I'd like to list eleven of the bullet points that were identified as qualifiers for future care in these new hospitals.  Then I'd like to ask those of you who have known, followed, or otherwise used us for your healthcare needs to identify which of those eleven are currently missing from this hospital environment, and, for that matter, which have not been a part of our experience here for the past decade?

1. Rather than report to a central admitting desk, patients and visitors are welcomed by greeters who escort them to appropriate locations.
   
   
2. Decor is focused on nature with earthy colors; indoor gardens, trees and fountains; and ample natural light.
   
   
3. It's much quieter thanks to sound-absorbing tiles, wireless communication, and limited overhead paging.
   
   
4. The lobby is consumer-centric with coffee shops, sitting areas, and kiosks for requesting information and scheduling appointments.
   
   
5. More attention is paid to way finding and signage, and hospital departments are given names that are less medical in nature.
   
   
6. Preventing disease and encouraging wellness are as important as diagnosing symptoms and treating illness.
   
   
7. Patient rooms are private, standardized, and bigger to allow overnight space for family members.
   
   
8. Patient rooms include built-in safety features like bathrooms located near patient beds to reduce falls and prominently placed sinks to encourage hand-washing.
   
   
9. For patient education and family entertainment, patient rooms and waiting ares are equipped with flat-screen TV's and Internet access.
   
   
10. Electronic records are standard practice.
    
    
11. In-home monitoring and diagnostic tools make it possible for patients to be diagnosed, treated, and monitored in their own homes.

 Maybe the better question to ask is: are there any ideas listed here that have not been put forth as challenges for implementation to our vice presidents, directors, or physician leaders?  Okay, we're not completely there yet, but we surely are close, and for Windber Medical Center the future has been NOW for quite some time.  The things not on this list that we do include:

• Comprehensive Integrative Medicine including: acupuncture, Reiki, massage, energy medicine, flower essence, music, spiritual healing programs, physical manipulation, stress management/yoga, humor, pet, and aroma therapy.
• Community based work-out facility.
• Genomic and proteomic affiliated research lab for translational medicine.
• Walking trails, meditation and healing gardens, outdoor fountains and labrynths.
• Cardiac disease reversal program
• On-campus Greenhouse
• Trans-fat-free menu
• Meals served to patients, families, and staff on each floor.
• Lots and lots of polite, nurturing tender loving care.

I rest my case...

 

Dream Weavers . . . on Leadership

The name selected was "The Dream Weavers",  The reason given for the name was that the songs they wrote were dreamy and they were therefore, weavers of dreams  . . . 

As a young band director, we would load the five buses with 185 instrumentalists and head to the stadium for an after-school football game.  Did I say that I was the ONLY adult involved?  Okay, I was a 22 year old adult, but, nevertheless . . . not a kid. 

Nine years later, at my last teaching job, there were 124 students and four buses with a Registered Nurse on each bus, four briefcases containing signed releases from each student's parents in the event that they needed medical care, and four more briefcases on each vehicle with additional information regarding their prescription drugs.  Finally, we also employed four assistants and recruited parent chaperones on each vehicle as well. 

During those ten years, the restrictions and the rules became more onerous.  I distinctly remember when we teachers were advised not to encourage the students with a pat on the back, a touch on the arm, a reassuring hug, or anything that could be considered in any way human. That was during the decade from 1969 to 1979, and life changed dramatically for the students and their teachers as they searched for verbal substitutions to replace these signs of supportive affection. I left teaching that year.

My career in hospital administration has ranged from 1988 to the present.  As you might have guessed, our involvement with attorneys and regulators has grown exponentially, too.  In fact, our annual legal fees usually are equal to the annual payments necessary on a major piece of diagnostic equipment; nearly the same as our heating bill. The most difficult thing that these specialists bring to my life is their comprehensive knowledge of every possible nuance of the law and the potential implications and ramifications of each of these potential legal wrinkles, the why nots. 

As the science of leadership is analyzed, as the structure of Windber Medical Center, Windber Research Institute, The Joyce Murtha Breast Center and HealthStyles, The Ornish Program, et al are dissected, not unlike a symphony, what will be revealed is not the power of analytical interpretation, but that of intuition, of humanness, of the expression of true kindness, and of inspiration. 

It wasn't the business plans, the financial experts, or the building analyzers that brought these ideas to life; to this hill of dreams.  It will not be the science of business that will be revealed, nor the quantitative rationalizations of gantt charts, algorithms, or financial plans.  It will be the revelation that people truly want to be treated like human beings; that they are looking for hope, for dignity, for respect, for comfort, and for unquestioning, unequivocal love.  

We are surrounded by things that can hurt us, can discourage us, and can stop us.  What we are not surrounded with is encouragement, belief, trust, and, many times, those willing to take a risk with us.  Leadership is most often lonely, and usually discouraging, but persistence, inner strength, and the creation of excitement through the pursuit of dreams is the key.

Let the legal minds dictate the nuances of the law, the potential ramifications of interpretation, the subtleties of risk.  Let the accountants dictate the numbers, and let the planners plan and plan.  Let the detailers detail, and the management experts suggest. Their work does not create the future. 

Intuition and sensitivity will help us reach our dreams. 

Love the dreamers, for they are at risk of extinction.  Embrace the creatives because they will always be the dream weavers. 

Remember that science comes from science fiction, that excitement comes from ideas, that leadership involves risk, and risk creates excitement. 

If you are not about risk and dreams, then you are not about leadership.